Effect of a Quality-Improvement Intervention on End-of-Life Care in the Intensive Care Unit

Curtis, J. Randall; Nielsen, Elizabeth; Treece, Patsy D.; Downey, Lois; Dotolo, Danae; Shannon, Sarah E.; Back, Anthony L.; Rubenfeld, Gordon D.; Engelberg, Ruth A.

doi:10.1164/rccm.201006-1004oc

Cited by 231 publications

(275 citation statements)

References 48 publications

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“…36 This speaks to the difficulty of changing practice patterns of large groups of providers on an institutional level. 1,[60][61][62] While the intervention team trained hundreds of people at each medical center, many staff had very little contact with the trainers (≤ an hour), which may have diluted the intervention effects. In addition, staff training lasted only 2 weeks.…”

Section: Discussionmentioning

confidence: 99%

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

et al. 2014

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BACKGROUND: Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. OBJECTIVE: To evaluate the effectiveness of a multimodal intervention strategy to improve processes of end-of-life care in inpatient settings. DESIGN: Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. PARTICIPANTS: Six Veterans Affairs Medical Centers (VAMCs). INTERVENTION: Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. MAIN MEASURES: Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n= 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, donot-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. KEY RESULTS: Significant intervention effects were observed for orders for opioid pain medication (OR:

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Section: Discussionmentioning

confidence: 99%

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

et al. 2014

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“…For example, despite being rigorously developed and studied among more than 4000 deaths, few studies have found effects of interventions on family members' ratings of the Quality of Dying and Death (QODD) questionnaire [11], including a large randomized trial of a palliative care intervention [12]. If these and other scales are known to be reliable and to validly measure appropriate constructs, what might explain the discouraging results of studies designed to improve family-reported outcomes?…”

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confidence: 99%

Life after death in the ICU: detecting family-centered outcomes remains difficult

2017

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Family members of patients who die in the ICU experience significant and lasting psychological burdens, such as post-traumatic stress disorder (PTSD), anxiety, depression, and prolonged grief [1,2]. Among the many potential contributors to these adverse bereavement outcomes are the circumstances surrounding and processes of limiting life support. This hypothesis is supported by evidence that ICU deaths are commonly preceded by decisions to withdraw life support [3], and evidence that both ICU processes of care [4,5] and behaviors of ICU clinicians [1,6] near the end of life can influence family members' post-ICU psychological outcomes. Thus, uncertainty regarding which approaches to withdrawing mechanical ventilation are least distressing for patients and families [7,8] represents an important area for rigorous investigation.In this context, Reignier and colleagues performed a prospective observational cohort study to compare psychological symptoms in over 400 family members of patients who died after withdrawal of mechanical ventilation by immediate extubation vs. terminal weaning in 43 French ICUs [9]. Impressively, the authors were able to assess the primary endpoint of PTSD symptoms 3 months after death among over 95% of enrolled family members. Secondary endpoints included symptoms of anxiety, depression, and complicated grief among family members, symptom burdens of patients during the dying process, and strains on ICU staff.The authors found no differences between groups in any of the psychological outcomes reported by family members at 3 months. This was a durable finding when adjusted for patient characteristics and center effects, and at 6-and 12-month follow-up assessments. ICU staff experienced similar levels of job strain regardless of the withdrawal method chosen, with the exception of nursing assistants who reported less strain with immediate extubation. Patients in the immediate extubation group experienced more gasping and airway obstruction and received significantly lower doses, on average, of sedatives and analgesics compared to those undergoing terminal weaning. Given these results, the authors conclude that the choice between these two approaches to withdrawal of mechanical ventilation does not impact psychological symptoms among family members. They also suggest, and we agree, that standardized approaches to medication administration near the end of life may reduce patient suffering.This study is innovative in empirically evaluating the impact of how mechanical ventilation is withdrawn on family-centered outcomes. It is also strengthened by the diverse sample of ICUs, and the outstanding follow-up rate. However, the ability to draw conclusions is tempered by the non-randomized design. Although the authors appropriately note that randomly assigning ICUs to an unfamiliar withdrawal method might engender low adherence to the assigned interventions, the observational design amounts to a comparison of withdrawal methods on family members who chose (or whose clinicians chose for them) a particul...

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“…While one large trial of an integrative ICU-based palliative care approach studied in 22 French ICUs was associated with significant decreases in family member anxiety, depression, and post-traumatic stress disorder levels [14], only a handful of ICU-based palliative care studies [15][16][17] have measured family-reported outcomes other than ''family satisfaction''. Moreover, ICU-based palliative care trials have thus far not measured truly patient-centered outcomes, such as symptom scores or quality of life [18].…”

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confidence: 99%

Tasking the tailor to cut the coat: How to optimize individualized ICU-based palliative care?

Aslakson¹,

Spronk

2015

Intensive Care Med

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Effect of a Quality-Improvement Intervention on End-of-Life Care in the Intensive Care Unit

Cited by 231 publications

References 48 publications

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

Life after death in the ICU: detecting family-centered outcomes remains difficult

Tasking the tailor to cut the coat: How to optimize individualized ICU-based palliative care?

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